RETINOPATIA - Investigaciones Foscali .RETINOPATÍA HIPERTENSIVA • Neovascularización retiniana

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  • RETINOPATIA

    HIPERTENSIVACARLOS MARIO RANGEL G, MD

    OFTALMOLOGIA

    UVEITIS

    RETINA Y VITREO

  • THE RETINA IS THE ONE PLACE IN THE BODY WHERE

    THE PHYSICIAN CAN ACTUALLY DIRECTLY INSPECT THE

    BODYS MICROVASCULATURE, THE TISSUE MOST

    DIRECTLY AT RISK FROM HYPERTENSION

    Spence JD, Fraser JA. Retinal vasculature: a window on the brain. Hypertension 2013; 62:678 679.

  • INTRODUCCIN

    HTA

    PAS 140 mmHg y/o PAD 90 mmHg

    Problema mayor de salud pblica

    9.4 millones muertes al ao a nivel

    mundialLim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990 2010:

    a systematic analysis for the Global Burden of Disease Study 2010. Lancet (London, England) 2012; 380:2224 2260.

    World Health Organization. A global brief on hypertension. Geneva: World Health Organization; 2013.

    RETINOPATIA HIPERTENSIVA

  • INTRODUCCIN

    HTA: modificaciones fisiopatolgicas

    Circulacin retiniana, coroidea y nervio ptico

    Retinopata hipertensiva: la manifestacin mas comn

    ACV

    Falla Cardiaca Congestiva

    Mortalidad Cardiovascular

    Ong YT, Wong TY, Klein R, et al. Hypertensive retinopathy and risk of stroke. Hypertension 2013; 62:706 711.

    Wong TY, Mitchell P. The eye in hypertension. Lancet (London, England) 2007; 369:425 435.

    RETINOPATIA HIPERTENSIVA

  • MANIFESTACIONES

    OCULARES DE

    HIPERTENSIN ARTERIAL

    RETINOPATIA HIPERTENSIVA

  • 1. Retinopata Hipertensiva

    2. Coroidopata Hipertensiva

    3. Neuropata ptica Hipertensiva

    4. Complicaciones Vasculares Retinianas

    Lazaros Konstantinidis and Yan Guex-Crosier. Hypertension and the eye . Curr Opin Ophthalmol 2016, 27:514 521

    RETINOPATIA HIPERTENSIVA

  • 1. Retinopata Hipertensiva

    2. Coroidopata Hipertensiva

    3. Neuropata ptica Hipertensiva

    4. Complicaciones Vasculares Retinianas

    Lazaros Konstantinidis and Yan Guex-Crosier. Hypertension and the eye . Curr Opin Ophthalmol 2016, 27:514 521

    RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA

    Manifestacin mas comn de HTA

    Elevacin aguda y/o crnica de TA

    Cambios vasculares retinianos que

    reflejan la severidad y duracin de la HTA

    Ahn SJ, Woo SJ, Park KH. Retinal and choroidal changes with severe hypertension and their association with visual outcome. Invest Ophthalmol Vis Sci 2014; 55:7775 7785.

    RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA

    RETINOPATIA HIPERTENSIVA

    Tso MO, Jampol LM. Pathophysiology of hypertensive retinopathy. Ophthalmology 1982;89(10):113245.

    VASOCONSTRICTORA

    EXUDATIVA

    ESCLERTICAFASES

  • Clasificacin

    Keith-Wagener-Barker

    Keith NM, Wagener HP, Barker NW. Some different types of essential hyper- tension: their course and prognosis. Am J Med Sci 1974; 268:336 345.

    Grado Hallazgos

    1 Estrechamiento arteriolar

    2 Cruces AV

    3 Hemorragias y exudados

    4 Papiledema

    RETINOPATIA HIPERTENSIVA

    RETINOPATA

    HIPERTENSIVA

  • I 2

    3 3

    4

  • RETINOPATA

    HIPERTENSIVA

    Clasificacin mas usada

    No es sensible para diferenciar Grado 1 de

    Grado 2

    Cuspidi C, Sala C, Grassi G. Updated classification of hypertensive retinopathy: which role for cardiovascular risk stratification? J Hypertens 2015; 33:2204 2206.

    RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA Clasificacin

    Mitchell-Wong

    Grado Hallazgos

    Leve

    Estrechamiento arteriolar generalizado y focal,

    muescas AV, opacificacin pared arteriolar o

    combinacin

    ModeradaHemorragias, microaneurismas, manchas blanco-

    algodonosas, exudados duros o combinacin

    MalignaSignos de retinopatia moderada con edema del disco

    ptico, PAS 180mmHg y/o PAD 120mmHgWong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004; 351:2310 2317.

    RETINOPATIA HIPERTENSIVA

  • LEVE MODERADA

    MALIGNA

    15

  • RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA

    Edema macular

    Puede ocurrir en

    casos de retinopata

    hipertensiva maligna

    Causa importante de

    disminucin de AV

    Steinegger K, Bergin C, Guex-Crosier Y. Malignant hypertension: clinical manifestations of 7 cases. Klin Monbl Augenheilkd 2015; 232:590 592.

    RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA

    Clasificacin

    Seong Jonn Ahn (OCT)

    Ahn SJ, Woo SJ, Park KH. Retinal and choroidal changes with severe hypertension and their association with visual outcome. Invest Ophthalmol Vis Sci 2014; 55:7775 7785.

    Grado Hallazgos

    Leve-Moderada KWB 1,2,3

    Maligna KWB 4 sin lquido subretiniano

    Maligna KWB 4 con lquido subretiniano

    RETINOPATIA HIPERTENSIVA

  • RETINOPATIA HIPERTENSIVA

  • RETINOPATA

    HIPERTENSIVA

    Neovascularizacin retiniana

    Secundaria a isquemia

    retiniana

    Hemorragia supracoroidea

    espontnea

    Raro

    RETINOPATIA HIPERTENSIVA

    Georgiadis O, Kabanarou SA, Batsos G, et al. Bilateral hypertensive retinopathy complicated with retinal neovascularization: panretinal photocoagulation or

    intravitreal anti-VEGF treatment? Case Rep Ophthalmol 2014; 5:231 238.

    Cheung AY, David JA, Ober MD. Spontaneous bilateral hemorrhagic chor- oidal detachments associated with malignant hypertension. Retin Cases Brief Rep 2016.

  • RETINOPATA

    HIPERTENSIVA

    TRATAMIENTO

    Manejo antihipertensivo

    Mejora de los cambios en HTA maligna

    Laser o AntiVGEFStrachan MW, McKnight JA. Images in clinical medicine. Improvement in hypertensive retinopathy after treatment of hypertension. N Engl J Med 2005; 352:e17.

    Kim EY, Lew HM, Song JH. Effect of intravitreal bevacizumab (Avastin((R))) therapy in malignant hypertensive retinopathy: a report of two cases. J Ocul Pharmacol Ther 2012; 28:318 322.

    Georgiadis O, Kabanarou SA, Batsos G, et al. Bilateral hypertensive retinopathy complicated with retinal neovascularization: panretinal photocoagulation or intravitreal anti-VEGF treatment?

    Case Rep Ophthalmol 2014; 5:231 238.

    RETINOPATIA HIPERTENSIVA

  • 1. Retinopata Hipertensiva

    2. Coroidopata Hipertensiva

    3. Neuropata ptica Hipertensiva

    4. Complicaciones Vasculares Retinianas

    Lazaros Konstantinidis and Yan Guex-Crosier. Hypertension and the eye . Curr Opin Ophthalmol 2016, 27:514 521

    RETINOPATIA HIPERTENSIVA

  • COROIDOPATIA

    HIPERTENSIVA Necrosis fibrinoide de la coroides

    No perfusin de la coriocapilaris

    Necrosis isqumica del EPR

    Acumulacin fluido subretiniano

    Signos: Elsching spots - Siegrist streaks

    Elschnig A. Die diagnostische and prognostische Bedeutung der Netzhau- terkrankungen bei Nephritis. Wien Med Wochenschr 1904; 53:445 452.

    RETINOPATIA HIPERTENSIVA

  • 1. Retinopata Hipertensiva

    2. Coroidopata Hipertensiva

    3. Neuropata ptica Hipertensiva

    4. Complicaciones Vasculares Retinianas

    Lazaros Konstantinidis and Yan Guex-Crosier. Hypertension and the eye . Curr Opin Ophthalmol 2016, 27:514 521

    RETINOPATIA HIPERTENSIVA

  • NEUROPATIA PTICA

    HIPERTENSIVA Producido por HTA maligna o

    acelerada

    Mecanismos: isquemia,

    aumento presin intracraneal,

    encefalopata hipertensiva

    Riesgo aumentado de

    mortalidad

    Manejo antihipertensivo

    urgenteCarol Yim Lui Cheung TYW. Hypertension. In: Retina, 5th ed Saunders: Elsevier Inc; 2013. pp. 1001 1005.

    RETINOPATIA HIPERTENSIVA

  • 1. Retinopata Hipertensiva

    2. Coroidopata Hipertensiva

    3. Neuropata ptica Hipertensiva

    4. Complicaciones Vasculares Retinianas

    Lazaros Konstantinidis and Yan Guex-Crosier. Hypertension and the eye . Curr Opin Ophthalmol 2016, 27:514 521

    RETINOPATIA HIPERTENSIVA

  • COMPLICACIONES

    VASCULARES RETINIANAS

    Oclusiones venosas retinianas

    Oclusiones arteriales retinianas

    Macroaneurismas arteriales retinianos

    RETINOPATIA HIPERTENSIVA

  • VALOR DE LA

    EVALUACIN CLNICA

  • VALOR DE LA

    EVALUACIN CLNICA Cuestionado 2011 British Society of Hypertension

    Fundoscopia: evaluar riesgo cardiovascular y dao de rgano

    blanco

    2013 European Society of Hypertension - European Society of

    Cardiology

    Dudas sobre el valor predictivo retinopata leve como signo

    especfico de dao de rgano blanco

    Excluyen fundoscopia del examen de rutina para HTA grado 1 y

    2Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial

    hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281 1357.

    RETINOPATIA HIPERTENSIVA

  • VALOR DE LA

    EVALUACIN CLNICA Retinopata Hipertensiva leve: FR para muerte

    cardiovascular

    Asociacin de Retinopata Grado 3-4 con dilatacin

    AI, hipertrofia VI, reduccin FE

    < 55 aos asociacin significativa entre Retinopata

    Hipertensiva leve y Dao de rgano BlancoSairenchi T, Iso H, Yamagishi K, et al. Mild retinopathy is a risk factor for cardiovascular mortality in Japanese with and without hypertension: the Ibaraki Prefectural Health Study. Circulation 2011; 124:2502 2511.